Use of levocetirizine and montelukast in the treatment of traumatic injury

ABSTRACT

The embodiments described herein include methods and formulations for treating lung and brain injury. The methods and formulations include, but are not limited to, methods and formulations for delivering effective concentrations of levocetirizine and montelukast to a patient in need. The methods and formulations can comprise conventional and/or modified-release elements, providing for drug delivery to the patient.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.15/348,253, filed Nov. 10, 2016, which is a continuation of U.S. patentapplication Ser. No. 14/831,469, filed Aug. 20, 2015, which is acontinuation of International Application No. PCT/US2014/021706, filedMar. 7, 2014, which claims the benefit of priority to U.S. ProvisionalPatent Application No. 61/780,336, filed Mar. 13, 2013. The foregoingapplications are fully incorporated herein by reference in theirentireties for all purposes.

BACKGROUND

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS)were defined by a panel of experts in 2011 (an initiative of theEuropean Society of Intensive Care Medicine endorsed by the AmericanThoracic Society and the Society of Critical Care Medicine) as theBerlin Definition. Presently there are three stages: mild, moderate, andsevere with an associated increased mortality and increased medianduration of mechanical ventilation in survivors. As shown by the BerlinDefinition of Acute Respiratory Distress Syndrome (Table VII), thecategories of ARDS are based in part on the degree of hypoxemiadetermined by the ratio of PaO2/FiO2, where the PaO2 is the partialpressure of oxygen in arterial blood and the FiO2 is the fraction ofinspired oxygen. Management of ARDS includes treatment of the underlyingcondition, mechanical or noninvasive ventilation, fluid and hemodynamictherapy, treatment of opportunistic infection, nutrition, andpharmacologic therapy. Currently there is no specific pharmacologictherapy for ALI/ARDS. Agents that have failed in large trials include inpart, glucocorticoids, alprostadil, surfactant, ketoconazole,N-acetylcysteine, procysteine, lisofylline, and site-inactivatedrecombinant factor VIIa. Given the concern for the increased risk ofnosocomial infection or critical illness polyneuropathy, as well as thelack of improvement in mortality, the routine use of glucocorticoids inARDS is not recommended.

Hypoxic-ischemic brain injury is a general classification of braininjury which includes, in part, brain trauma, cardiac arrest, vascularcatastrophe (hemorrhagic, thrombotic stroke), poisoning (such as carbonmonoxide or drug overdose) and central nervous system infection.Improved techniques have resulted in greater numbers of patientssurviving with variable degrees of brain injury. The evolution ofhypothermic treatment has been particularly useful in improvingneurologic morbidity and decreasing mortality in survivors of cardiacarrest and major brain trauma. The induction of mild to moderatehypothermia to a target temperature of 32-34° C. has improved theneurologic outcomes; however, refinement of existing protocols withvalidated studies are needed.

Supportive and preventive care measures remain the mainstay of therapyin all forms of hypoxic-ischemic brain injury. In additions to concertedefforts to restore the central nervous system to its pre jury state,clinicians are additionally focused on preventing nosocomial infection,providing adequate nutrition and providing adequate prophylaxis againstvenous thromboembolism, and gastric stress ulceration.

Severe traumatic brain injury is defined as head trauma associated witha GlasgowComa Scale (GCS) score of 3-8. Traditionally, steroids wereused in high doses for the treatment of traumatic brain injury todecrease the swelling and edema cause by the primary injury (such asskull fracture, cerebral contusion, and hemorrhage). However, morerecently, a consensus of opinion holds that high-dose steroids increasethe risk of secondary infection, gastric ulceration, electrolyteimbalance, fluid retention, and steroid induced diabetes mellitus.Moreover, high-dose methylprednisolone in the treatment of patients withsevere traumatic brain injury was recently considered acontraindication.

SUMMARY

Certain embodiments provide methods of treating traumatic injury or asymptom of traumatic injury in a patient in need thereof. In someembodiments, the method comprises administering an effective amount of acombination of levocetirizine and montelukast to the patient.

In some embodiments, a method of treating lung injuries and braininjuries in a patient in need thereof is disclosed. In some embodiments,the method comprises administering to the patient an effective amount ofa combination of levocetirizine and montelukast.

In a variation, a method of treating a lung injury in a patient in needis disclosed. The method comprises administering to the patient aneffective amount of a combination of levocetirizine and montelukast.

In another variation, a method of treating a symptom of a lung injury ina patient in need thereof is disclosed. The method comprisesadministering to the patient an effective amount of a combination oflevocetirizine and montelukast.

In a variation, a method of treating a brain injury in a patient in needis disclosed. The method comprises administering to the patient aneffective amount of a combination of levocetirizine and montelukast.

In another variation, a method of treating a symptom of a brain injuryin a patient in need thereof is disclosed. The method comprisesadministering to the patient an effective amount of a combination oflevocetirizine and montelukast.

Any of the method described above, or described elsewhere herein, caninclude one or more of the following features.

The combination of levocetirizine and montelukast may be administered atthe onset of symptoms for any of the disclosed methods. In some cases,the symptoms could precede the overt clinical presentation dependingupon the nature and extent of the disease process, by days, weeks,months or even years, e.g., headache preceding a major stroke.

The combination of levocetirizine and montelukast may be administered atthe time of diagnosis for any of the disclosed methods.

The combination of levocetirizine and montelukast may be administered ina sequential manner for any of the disclosed methods.

The combination of levocetirizine and montelukast may be administered ina substantially simultaneous manner for any of the disclosed methods.

In some embodiments of the disclosed methods, an additional active agentmay be administered. Additional active agents include, but are notlimited to, the broad spectrum of antibiotics, antivirals,anti-parasitics, antifungals, vasopressors, diuretics, anticoagulants,anti-seizure medications, proton pump inhibitors, glucocorticoids, H2receptor antagonists, anti-inflammatories and anti-neoplastic drugs, orcombinations thereof. For example, the antibiotic can be vancomycin,meropenem, amoxicillin/beta clauvulanic acid, levofloxacin,piperacillin/tazobactam, ceftriaxone, clindamycin, azithromycin,trimethoprim/sulfamethoxazole, doxycycline or combinations thereof.

In some embodiments of the disclosed methods, the combination may beadministered to the patient by one or more of the routes consisting ofenteral, intravenous, intraperitoneal, inhalation, intramuscular,subcutaneous and oral.

In some embodiments, the levocetirizine and montelukast may beadministered by the same route.

One embodiment is directed to methods, formulations and kits fortreating acute lung or brain injuries. The methods and formulationsinclude, but are not limited to, methods and formulations for deliveringeffective concentrations of levocetirizine and montelukast to a patientin need. The methods and formulations can comprise conventional and/ormodified-release elements, providing for drug delivery to the patient.

In some embodiments, a combination of levocetirizine and montelukast,either as a single formulation or as separate formulations, may beadministered as an emergency medication. For example, in someembodiments, a combination of levocetirizine and montelukast, either asa single formulation or as separate formulations, may be administeredimmediately at the onset of symptoms. In some embodiments, a combinationof levocetirizine and montelukast, either as a single formulation or asseparate formulations, may be administered substantially close to theonset of symptoms or at the time of diagnosis.

In some embodiments, the methods of treatment, formulations and kits mayinclude e.g., a bilayer tablet, comprising levocetirizine andmontelukast in separate layers, for daily administration. Alternatively,each medication may be administered separately (one tablet oflevocetirizine and one tablet of montelukast per day in the evening). Insome embodiments, a combination of levocetirizine and montelukast,either as a single formulation or as separate formulations, may beadministered for 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15days for the treatment of lung or brain injury. The bilayer tablets orthe separate tablets may be packaged in a blister pack supplied for a 7to 10 day course of therapy, with instructions including indications,administration instructions and precautions. In some embodiments, acombination of levocetirizine and montelukast, either as a singleformulation, such as a bilayer tablet, or as separate formulations, maybe administered for approximately 15, 20, 30, 60, 90 or more days ormore for the treatment of lung or brain injury. Depending upon thenature and extent of the injuries, an extended treatment period may berequired to clear blood from the perinasal sinuses and/or to foreshortenhealing times, particularly in those patients undergoing multipleprocedures during their hospitalization. The bilayer tablets or theseparate tablets may be packaged in a blister pack supplied for a 30 daycourse of therapy, with instructions including indications,administration instructions and precautions. In some embodiments, thelevocetirizine and montelukast, may be independently administered vianasogastric tube 1, 2, 3, 4, 5, 6, 7 or 8 times per day.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows a diagram of the proposed anti-inflammatory mechanism ofaction of levocetirizine and montelukast utilizing a steroid modelpathway.

FIGS. 2A-B show digital radiographic CT images of a patient. FIG. 2Ashows CT images taken of the chest of an eighteen year old male traumapatient presenting with brain, lung, facial, and liver injuries (SeeExample 1). FIG. 2A shows a CT image of the patient's chest withcontrast, hospital day number 4; thirty six hours following theinstitution of levocetirizine plus montelukast. Failure to rapidlyprogress on the synergistically acting anti-inflammatory molecules leadto a bronchoscopy for removal of a retained foreign body (food). Thepatient was thereafter successfully extubated approximately 1.5 dayslater. FIG. 2B shows a montage image of the patient's brain withoutcontrast, 72 hours following the injury and approximately 30 hoursfollowing initiation of levocetirizine plus montelukast. The cerebraledema has stabilized. Concurrently there has been a slight intervalimprovement in the patient's bilateral frontal lobe contusions.

FIG. 3 shows a chest x-ray image taken of the patient, hospital day #8and 5.5 days on combined therapy. The bibasilar opacities have almostcompletely resolved (See Example 1).

FIG. 4 shows digital radiographic CT images taken of the chest of anineteen year old male with aspiration pneumonia and pulmonary contusionshortly after presentation to the hospital (See Example 2). The CT imageis consistent with pulmonary contusion and aspiration prior totreatment.

FIGS. 5A-B show x-ray images of the chest of a nineteen year old malepatient. The patient had aspiration pneumonia and pulmonary contusion(See Example 2). FIG. 5A shows an image taken prior to the initiation oftherapy, as the condition is worsening in the early morning hoursfollowing admission (moderate ARDS by the Berlin definition). FIG. 5Bshows an image taken 8 days following injury and treatment with thecombined medication, levocetirizine plus montelukast. The chest x-rayhas cleared. The patient was extubated hospital day number 2 anddischarged hospital day number 4. The mean intubation time for moderateARDS as defined by the Berlin definition is 7 days.

FIG. 6 shows a diagram of the Glasgow Coma Scale (GCS). The GCS rangesfrom 3-15 and is an assessment tool used by emergency medical providersto objectively provide a degree of consciousness.

FIG. 7 shows a diagram that compares the effects of intravenous and oralmontelukast on airway function.

DETAILED DESCRIPTION

The present embodiments relate to the combination of levocetirizine andmontelukast as a medicament for the treatment of acute, subacute andchronic inflammation. Several embodiments relate to the combination oflevocetirizine and montelukast for the treatment of non-IgE-mediated,IgE-mediated, and/or combined non-IgE-mediated and IgE-mediatedinflammation. Traditional allergic rhinitis is an IgE mediated disease;up to 70-80% of patients with asthma also have allergic rhinitis (atopicasthma). Administration of levocetirizine and montelukast in combinationexhibits synergistic effects and unexpectedly superior results in thetreatment of influenza, common cold, allergic rhinitis and acute,subacute, and chronic inflammation. Moreover, combinations oflevocetirizine and montelukast can be used safely in conjunction withmany existing treatment protocols.

Levocetirizine is an antihistamine and montelukast is a leukotrienereceptor antagonist. As described herein, synergy between levocetirizineand montelukast shortens the course of the disease processes, therebydecreasing morbidity and mortality. This combined therapy also canimprove quality of life from the amelioration of symptoms/sideeffects/disease process itself, and can decrease health-care costs. Thissynergistic effect can be observed in the use of a combination oflevocetirizine and montelukast to treat non-IgE-mediated inflammationand combined non-IgE-mediated and IgE-mediated inflammation. Not wishingto be bound by a particular theory, the non-IgE-mediated response may berelated, at least in part, to the fact that both levocetirizine andmontelukast affect eosinophil migration, the leukocyte that isconsidered a hallmark of inflammation.

Levocetirizine, a potent H1-antihistamine, acts primarily bydown-regulating the H1 receptor on the surface of mast cells andbasophils to block the IgE-mediated release of histamine which cause thecardinal symptoms of allergic rhinitis: sneezing, rhinorrhea, nasalcongestion, itchy palate and itchy red and watery eyes. Levocetirizineoffers a short time to peak plasma level, 0.9 hr., a short time tosteady state level, 40 hours, a low volume of distribution, 0.4 L/kg,and an enhanced receptor affinity of 5× over first generation mepyraminein an acidic pH (many acute inflammatory disease states are associatedwith acidosis, a low physiologic pH). Levocetirizine has a 24 hourreceptor occupancy of ˜75%, the highest of the commercially availableantihistamines. Receptor occupancy of the second generationantihistamines appears to correlate with the pharmacodynamic activity inskin wheal and flare studies and with efficacy in allergen challengechamber studies. Levocetirizine is approved in the US for the treatmentof perennial allergic rhinitis and chronic idiopathic urticaria down tosix months of age.

Levocetirizine has been objectively established as the most potent ofthe five modern generation antihistamines through histamine inducedwheal and flare data. For example, levocetirizine at 5 mg per day ismore effective than fexofenadine at its commonly prescribed dose of 180mg per day in the United States. In Europe the adult dose is 120 mg perday. Levocetirizine has a lower volume of distribution, greaterhistamine receptor affinity in an inflamed state (low pH), and greaterreceptor occupancy at 24 hours at physiologic doses than fexofenadine.The corresponding values are shown in Table I.

TABLE I COMPARISON BETWEEN FEXOFENADINE AND LEVOCETIRIZINE FexofenadineLevocetirizine Vd-L/kg 5.6 L/kg 0.4 L/kg Receptor affinity in an acidicph increased 2x increased 5x Histamine receptor occupancy at ~25% ~75%24 hours Steady-state level 3 days 40 hours

Levocetirizine decreases human rhinovirus titers in vitro by log-2. Notto be bound by a particular theory, the cellular mechanism of action isa proposed reduction of the activation of the intracellular proteincomplex NF-kB (nuclear factor kappa B) which is in turn responsible forthe reduction of I-CAM-1. I-CAM-1, a transmembrane protein, is viewed asthe portal of entry of human rhinovirus into the cell. Rhinovirus can befound in ˜50% of cases of acute asthma and is responsible for 30-50%cases of the ‘common cold.’ A one-log reduction in viral titers has beenindependently determined to correlate with improved symptoms. Inaddition, levocetirizine has been shown to decrease eosinophil migrationand decrease inflammatory mediators, IL-4, IL-6, and IL-8. IL-6, asignaling protein, regulates in part: fever, the body's response totrauma, and the acute (immediate) phase of the allergic reaction.

Montelukast, a leukotriene receptor antagonist, acts by binding withhigh affinity and selectivity to the CysLT1 receptor to inhibit thephysiologic actions of the leukotriene LTD4. Leukotrienes are fattysignaling molecules whose effects include airway edema, smooth musclecontraction and altered cellular activity associated with theinflammatory process. Overproduction of leukotriene is a major cause ofinflammation in asthma and allergic rhinitis. The cysteinyl leukotrienes(LTC4, LTD4, LDE4) are products of arachidonic acid metabolism. Theseleukotrienes are released from various cells including mast cells andeosinophils. They bind to receptors in the human airway and on otherpro-inflammatory cells including eosinophils and certain myeloid stemcells. The cysteinyl leukotrienes have been correlated with thepathophysiology of asthma and allergic rhinitis.

Leukotriene D₄ is the most potent of the cysteinyl leukotrienes incontracting airway smooth muscle. Leukotriene receptors, such as CysLT₁,are found throughout the cells of the respiratory tree (including airwaysmooth muscle cells and airway macrophages) as well as on otherpro-inflammatory cells in the body, particularly eosinophils and certainmyeloid stem cells. Leukotrienes also function to promote therecruitment of eosinophils, dendritic cells and T cells. Eosinophilinfiltration is considered by some authorities as a hallmark ofinflammation.

Montelukast is FDA approved in the US for the treatment of perennialallergic rhinitis, asthma, seasonal allergic rhinitis, and exercisedinduced bronchospasm. Montelukast has been shown to be ineffective inimproving asthma control or cold symptom scores caused by experimentalrhinovirus infection. See Kloepfer K M, et al., Effects of montelukastin patients with asthma after experimental inoculation with humanrhinovirus 16. Annals Allergy Asthma Immunology. 2011; 106:252-257.Unlike levocetirizine, no decrease in viral shedding was observed inrhinovirus-infected individuals treated with montelukast and there wasno significant difference in reported cold symptom scores compared toplacebo-treated individuals. Analysis of secondary outcomes suggeststhat montelukast may protect against reductions in lung function andincreases in sputum eosinophils caused by common cold infections. Duringthe recovery phase the percentage of sputum eosinophils was elevated inthe placebo group, while the montelukast group remained at baselinelevels. Further, peak expiratory flow was not decreased in themontelukast-treated patients. Other studies have shown that montelukasttreatment has no effect on the respiratory symptoms of patients withacute respiratory syncitial virus bronchiolitis. See Bisgaard, H., etal., Study of montelukast for the treatment of respiratory symptoms ofpost-respiratory syncitial virus bronchiolitis in children, Am. J.Respir. Crit. Care Med., 2008; 178:854-860; and Proesmans, M., et al.,Montelukast does not prevent reactive airway disease in young childrenhospitalized for RSV bronchiolitis, Acta Paediatr. 2009; 98:1830-34.However, some studies indicate that treatment with montelukast reducedthe number of days with worsened asthma symptoms and unscheduleddoctor's visits in children with mild allergic asthma and resulted in amodest reduction of symptoms in children with recurrent wheezing whengiven at the first sign of upper respiratory tract illness. See Sears,M. R. and Johnston, N. W., Understanding the September asthma epidemic.J. Allergy Clin. Immunol. 2007; 120:526-29; Bacharier, L. B., et al.,Episodic use of an inhaled corticosteroid or leukotriene receptorantagonist in preschool children with moderate-to-severe intermittentwheezing. J. Allergy Clin. Immunol. 2008; 122:1127-35.

Montelukast reaches a steady state level, like the second generationantihistamine, levocetirizine, in less than two days. Unlike othercurrently available leukotriene modulators, zileuton and zafirlukast,routine monitoring of liver function tests is not required. There are nodrug interactions with warfarin, theophylline, digoxin, terfenadine,oral contraceptives, or prednisone.

The two molecules are safe, i.e., FDA approved in the United States forallergic disorders down to age six months. They can be given primarilyor in conjunction with many of the existing therapeutic protocols forthe treatment of inflammation, including but not limited to, influenza,acute asthma and the common cold. Both medications are pregnancycategory B (Table II).

TABLE II PREGNANCY CATEGORY DEFINITIONS Category Definition ExplanationA Generally acceptable Controlled studies in pregnant women show noevidence of fetal risk. B May be acceptable Either animal studies showno risk but human studies not available or animal showed minor risks andhuman studies were done and showed no risk. C Use with caution if Animalstudies show risk and human studies not benefits outweigh risksavailable or neither animal nor human studies were done. D Use inlife-threatening Positive evidence of human fetal risk. emergencies whenno safer drug is available X Do not use in pregnancy Risks involvedoutweigh potential benefits. Safer alternatives exist.

Existing treatment of inflammation focuses on the underlying conditionand nature of the presentation. Commonly employed are a myriad of agentssuch as: diphenhydramine (Benadryl®), oxygen, epinephrine, steroids,beta-agonists, non-steroidal anti-inflammatory agents (NSAIDS),antipyretics, antibiotics, antifungals, and antivirals. Paradoxically,the commonly employed NSAIDS actually increase the production ofleukotrienes.

Steroids, which are widely used to treat inflammation, have significantshort and long-term side-effects (Table III). With regard to treatinginflammation associated with rhinosinusitis, nasal steroids have theirlimitations, particularly in the elderly and those patients on aspirin,clopidogrel or warfarin prescribed to reduce the risk of stroke andheart attack. Even in patients who do not take these traditional “bloodthinners,” the risk of spontaneous epistaxis from nasal steroid spraysis between 4-22%. The risk of epistaxis is medication dependent.Epistaxis is a significant consideration in many patients 55 or older.

TABLE III STEROID SIDE EFFECTS Short term Long term Increased propensityfor opportunistic Glaucoma infection Cataracts Increased blood pressureHigh-blood pressure Mood changes Heart disease Increased blood sugarDiabetes mellitus Increased intraocular pressure Obesity Water retentionAcid reflux/GERD Weight gain Osteoporosis Increased risk for congestiveheart failure Myopathy Flushing Increased propensity for Increasedappetite opportunistic infection Insomnia Cushing syndrome

The typical daily dosage for levocetirizine is 5 mg for adults, andlevocetirizine exhibits the following advantageous properties: i) Shorttime to reach peak plasma levels—0.9 hr; ii) Short time to steady statelevel—40 hrs; iii) Low volume of distribution (goes directly to thetarget receptor); iv) High receptor occupancy at 24 hours ˜75%; v)Increased receptor affinity in inflamed tissue (acidic pH; up to 5× thatof first generation molecules); vi) Pregnancy category B; vii) FDAapproved down to six months for other disease states, i.e., perennialallergic rhinitis and chronic idiopathic urticaria; viii)Anti-inflammatory properties; and ix) Anti-viral properties. Studies inhumans have shown that doses of levocetirizine up to 30 mg/day can besafely administered.

Montelukast, a leukotriene receptor antagonist, acts concurrently toprotect the respiratory tree as well as block mediators in theinflammatory cascade. The typical daily dosage of montelukast is 10 mgfor adults, and montelukast exhibits the following advantageousproperties: i) montelukast is a selective receptor antagonist,inhibiting the physiologic action of LTD₄ at the CysLT₁ receptor; ii)montelukast binds with high affinity and selectivity to the CysLT₁receptor without producing any agonist activity; iii) montelukast israpidly absorbed; iv) montelukast reaches a peak plasma concentration in3-4 hours; v) the oral bioavailability and C_(max) of montelukast arenot affected by a standard meal; vi) montelukast has a linearpharmacokinetics to 50 mg; vii) doses as low as 5 mg in adults causesubstantial blockage of LTD₄-induced bronchoconstriction; viii) in aplacebo controlled crossover study, montelukast inhibited early-phasebronchoconstriction due to antigen challenge by 75%; ix) montelukast isFDA approved down to six months of age; and x) montelukast has no druginteractions with warfarin, theophylline, digoxin, terfenadine, oralcontraceptives, or prednisone. Montelukast has been administered atdoses up to 200 mg/day to adult patients for 22 weeks and in short-termstudies, and up to 900 mg/day to patients for approximately one weekwithout clinically important adverse experiences.

Accordingly, both levocetirizine and montelukast are pregnancy categoryB in the United States and are FDA approved in the United States down tosix months of age for other disease processes. Moreover, both drugs haveonly once daily dosing, and no routine monitoring of blood work isnecessary for most clinical situations. Further, both drugs exhibitminimal clinically relevant interactions with other medications. Asdescribed herein, both levocetirizine and montelukast [administeredorally] reach steady state levels within two days to rapidly produce asynergistic and complementary anti-inflammatory effect.

Administration of montelukast and a second generation antihistamine,fexofenadine, has a synergistic effect in the treatment of allergicrhinitis. Allergic rhinitis, also known as pollenosis or hay fever, isan allergic inflammation of the nasal airways which occurs when anallergen such as pollen or dust is inhaled by an individual with agenetically susceptible immune system (estimated at greater than 20percent of the population). The allergen triggers antibody production, aserum specific immunoglobulin E (IgE), which in turn can bind to mastcells and basophils containing histamine. Upon re-exposure to theoffending antigen, histamine is released causing the itching, swelling,and mucus production which are well known to seasonal allergy suffers. Acombination of montelukast and fexofenadine reduced nasal congestionboth subjectively, using patient diary and VAS evaluations, andobjectively, using rhinomanometry and physical examination, withstatistical significance compared to fexofenadine alone or fexofenadinewith placebo.

However, the scientific literature does not clearly indicate whether thecombination of an antihistamine plus a leukotriene offers an advantageover each alone for treatment in general. For example, in one chronicinflammatory disease state, chronic idiopathic urticaria, montelukastdid not appear to offer an advantage over the second generationantihistamine desloratadine. See DiLorenzo G, et. al. Randomizedplacebo-controlled trial comparing desloratadine and montelukast incombined therapy for chronic idiopathic urticaria. J Allergy ClinImmunol 2004; 114-:619-25. Further, the FDA in April 2008 did approvethe combination of loratadine, also a second generation antihistamine,and montelukast for the treatment of allergic rhinitis and asthma,finding no benefit from a combined pill.

Here, we describe the unexpected synergistic effects of combininglevocetirizine and montelukast. Not wishing to be bound by a particulartheory, a detailed examination of the pharmacokinetics of levocetirizineat the cell level illuminates the unique inflammatory properties thatextend beyond the IgE mediated release of histamine. Levocetirizineexhibits a low volume of distribution (0.4 L/kg), prolonged dissolutiontime from the H1 receptor in an acidic pH, enhanced receptor affinity asa pure isomer of cetirizine, and the highest receptor occupancy at 24hours of any currently available antihistamine. Such parameters impartan inflammatory effect by down regulating IL-4, IL-6, IL-8 as well ascellular adhesion molecules. The later are a homogeneous group ofinducible immunoglobulins, integrins and selectins involved incell-to-cell adhesion, cellular recruitment, homing and healing. Inaddition levocetirizine has been shown in vivo to decrease ICAM-1, IL-6,IL-8, TLR3 expression and NF-kappa B activation resulting in decreasedhuman rhinovirus titers by log-2. Many rhinovirus serotypes share thesame cellular receptor identifying ICAM-1 as the portal of entry intothe cell. Levocetirizine inhibits rhinovirus-induced ICAM-1 and cytokineexpression and viral replication in airway epithelial cells. One logreduction in viral shedding results in a significant clinical benefit inHRV-infected (human rhinovirus) patients.

An unmet clinical need arose in 2009 with the H1N1 pandemic. The primarydrug of choice for influenza, oseltamivir, did not appear to reduceinfluenza related lower respiratory tract complications. Forneuraminidase inhibitors, there was a shortening of the illness by onlyone half to one day, which indicated that neuraminidase inhibitors donot prevent infection or stop nasal viral excretion, and therefore maybe a suboptimal means of interrupting viral spread in a pandemic.Moreover, during this time frame, California reported alarming data onthe severity of H1N1 influenza in pregnant and postpartum women, i.e.,from April 23 through Aug. 11, 2009, 22% of pregnant or postpartum womenrequired intensive care for the treatment of H1N1 and 8% died.Clinically it was demonstrated that the combination of levocetirizineplus montelukast (the latter added to protect the lower airway; both ofwhich were Pregnancy Category B), could be safely and effectively usedto ameliorate/shorten the course of influenza.

Not wishing to be bound by a particular theory, the steroid modelsuggests that levocetirizine acts in a non-IgE-mediated capacity at thelevel of NF-kB (See FIG. 1) whereas montelukast acts at the CysLT1receptor to inhibit the physiologic actions of LTD4. Both molecules areknown to reduce the quantity of eosinophils or their migration to siteof inflammation. Montelukast, in addition, also decreases therecruitment of dendritic cells and T cells.

The actions of levocetirizine plus montelukast surpass the individualphysiologic mechanisms of each, well beyond the treatment of allergicrhinitis and asthma. At least in part, it is the anti-viral andanti-inflammatory properties of levocetirizine vis-a-vis nuclear factorkB; the inhibition of the actions of LTD4 by montelukast, underscored byability of both levocetirizine and montelukast to inhibit the eosinophilquantity/migration, which impart synergy. This synergy is reflected bysignificantly improved clinical outcomes in a myriad of acute andchronic inflammatory disease states.

Embodiments described herein relate to methods of treating inflammationof the entire respiratory tree, including in part, the nose andparanasal sinuses known as rhinosinusitis with montelukast andlevocetirizine. Rhinosinusitis considered on a timeline may be acute,with a duration of less than six weeks (usually 4-6 weeks), subacute,having a duration of six to twelve weeks, or chronic, having a durationof greater than or equal to twelve weeks. Acute rhinosinusitis may beprecipitated by multiple factors not limited to chemical irritation,trauma, allergic rhinitis or an earlier upper respiratory tractinfection, which may be bacterial, viral, or, less commonly, fungal inorigin. The most common causative agents of acute sinusitis of bacterialorigin are Streptococcus pneumoniae, Haemophilus influenzae, Moraxellacatarrhalis, Staphylococcus aureus, other streptococci species,anaerobic bacteria, and, less commonly, gram negative bacteria.Bacterial sinusitis tends to be more persistent than viralrhinosinusitis, i.e., the common cold, which typically lasts for 7 to 10days.

Several embodiments described herein relate to the treatment of acuterhinosinusitis caused by a viral or bacterial infection with montelukastand levocetirizine. In some embodiments, montelukast and levocetirizineare taken prophylactically to prevent a viral respiratory tractinfection from escalating to an acute, often opportunistic, secondarybacterial sinusitis, bronchitis and/or pneumonia. In some embodiments,montelukast and levocetirizine are administered immediately, one hour, 6hours, 12 hours, 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days,8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 15 days, 16days, 17 days, 18 days, 19 days, 20 days, 21 days, 22 days, 23 days, 24days, 25 days, 26 days, 27 days, 28 days, 29 days, and/or 30 days afterexposure to the pathogens (virus, bacteria, fungi, etc.). Severalembodiments relate to the treatment of patients with clinicalmanifestations of influenza with montelukast and levocetirizine. In someembodiments, montelukast and levocetirizine treatment reduces theduration of influenza. In some embodiments, montelukast andlevocetirizine treatment reduces the severity of influenza symptoms.Several embodiments relate to the treatment of patients with clinicalmanifestations of the common cold with montelukast and levocetirizine.In some embodiments, montelukast and levocetirizine treatment reducesthe duration of the cold. In some embodiments, montelukast andlevocetirizine treatment reduces the severity of cold symptoms.

Chronic rhinosinusitis is an inflammatory condition/disease of the noseand paranasal sinuses lasting for greater than or equal to twelve weeks.Symptoms include in part, any combination of nasal congestion, facialpain, headache, coughing, an increase in asthma symptoms, malaise,discharge, feeling of facial tightness, dizziness, and/or aching teeth.Rhinosinusitis in general can be categorized into four categories: (1)acute bacterial rhinosinusitis (ABRS), (2) chronic rhinosinusitiswithout nasal polyposis (CRSsNP), (3) chronic sinusitis with nasalpolyposis (CRSwNP), and (4) allergic fungal rhinosinusitis (AFRS). SeeMeltzer, EO. Rhinosinusitis: Developing guidance for clinical trials. JAllergy Clin Immunol 2006 November; S20. Nasal polyposis is a subgroupof chronic rhinosinusitis in which the inflammation of the nose isassociated with two or more of the following signs and symptoms: nasalobstruction or congestion, nasal discharge, hyposmia or anosmia, facialpain or feeling of pressure, endoscopic evidence of polyps ormucopurulent discharge from middle meatus with or without edema ormucosal obstruction of the meatus and CT images which show mucosalchanges of osteomeatal complex or paranasal sinuses. See Fokkens W, et.al. EAACI position paper on rhinosinusitis and nasal polyps executivesummary. Allergy, 2005; 60, 583-601, Fokkens, W, et. al. EuropeanPosition Paper on Rhinosinusitis and Nasal Polyps group (2007) Europeanposition paper on rhinosinusitis and nasal polyps. Rhinology 2007; 20,1-136. Conventional treatment for chronic rhinosinusitis often involvesfunctional endoscopic sinus surgery, antibiotics, systemic and topicalsteroids, and to a much lesser extent an antihistamine or leukotrienemodulator. The use of antihistamines in patients with only polyps hasnot been extensively studied. See Casale M, et. al. Nasal Polyposis:From Pathogenesis to Treatment, an Update. Inflammation & Allergy—DrugTargets 2011, 10, 158-163. Mometasone furoate monohydrate, a topicalnasal steroid spray, is the only FDA approved medication in the UnitedStates for the treatment of nasal polyposis. The recommended dose is twosquirts each nostril twice a day.

Embodiments described herein relate to the treatment of chronicrhinosinusitis with montelukast and levocetirizine. Several embodimentsdescribed herein relate to the treatment of nasal polyposis withmontelukast and levocetirizine. In some embodiments, montelukast andlevocetirizine treatment reduces the size and/or number of polyps. Someembodiments relate to the treatment of chronic rhinosinusitis withmontelukast and levocetirizine in the absence of steroids, antibioticsor surgical treatment. In other embodiments, montelukast andlevocetirizine are administered in conjunction with antibiotics and/orsteroids and/or surgical treatment as deemed clinically applicable. Thechronic rhinosinusitis treatment protocol with or without othertreatment modalities is shown in Table IV.

TABLE IV TREATMENT PROTOCOL FOR CHRONIC RHINOSINUSITIS Levocetirizine -US Adults: 5 mg/day Children: 6-11 years of age: 2.5 mg/day Children: 6months to 5 years 1.25 mg/day Montelukast - US Adults: 10 mg orally/dayChildren 6-14 years of age: 5 mg orally/day Children 6 months-5 years ofage: 4 mg orally/day

Patients may be seen at least quarterly in the office with endoscopicreview of the nose/paranasal sinuses when clinically appropriate. Apretreatment and follow-up CT scan of the perinasal sinuses at 6 monthsto one year post initiation of therapy may be performed to provideobjective data on which to tailor existing medical therapy.

Several embodiments relate to a method of treating rhinitis withmontelukast and levocetirizine. Rhinitis, inflammation of the nasalpassages, is commonly caused by a viral or bacterial infection,including the common cold, the latter of which is caused primarily byRhinoviruses and Coronaviruses. See Eccles R. Understanding the Symptomsof the Common Cold and Influenza. Lancet Infectious Diseases 2005;5(11): 718-725. Rhinitis is categorized as: (i) infective rhinitis; (ii)nonallergic rhinitis; and (iii) allergic rhinitis. Several embodimentsrelate to a method of treating infective rhinitis with montelukast andlevocetirizine. Some embodiments relate to a method of treatingnonallergic rhinitis with montelukast and levocetirizine. Someembodiments relate to a method of treating allergic rhinitis withmontelukast and levocetirizine.

Several embodiments described herein relate to the treatment of chronicrhinosinusitis with montelukast and levocetirizine. Some embodiments,relate to the treatment of chronic rhinosinusitis with montelukast andlevocetirizine in the absence of steroid or antibiotic treatment. Inother embodiments, montelukast and levocetirizine are administered inconjunction with antibiotics and/or steroids.

Several embodiments relate to a method of treating non-IgE-basedinflammation with montelukast and levocetirizine.

Several embodiments relate to a method of treating combined IgE andnon-IgE-mediated inflammation with montelukast and levocetirizine.

Table V shows the existing U.S. national guidelines for dosages in thetreatment of allergic disorders.

TABLE V GUIDELINES FOR DOSAGES IN THE TREATMENT OF ALLERGIC DISORDERSLevocetirizine - US Adults: 5 mg/day Children: 6-11 years of age: 2.5mg/day Children: 6 months to 5 years 1.25 mg/day Montelukast - USAdults: 10 mg orally/day Children 6-14 years of age: 5 mg orally/dayChildren 6 months-5 years of age: 4 mg orally/day

Several embodiments relate to the use of a combination of levocetirizineand montelukast to treat a bacterial infection. Examples of bacterialinfections that may be treated by a combination of levocetirizine andmontelukast include, but are not limited to, acute bacterialrhinosinusitis (ABRS). In some embodiments, levocetirizine andmontelukast may be administered with an antibiotic as determined bylocal presentation.

Several embodiments relate to the use of a combination of levocetirizineand montelukast to treat otitis media with effusion and associated eardisorders such as chronic mastoiditis and eustachian tube dysfunction(the auditory tube leading from the back of the nose to the middle ear).In some embodiments, levocetirizine and montelukast may be administeredwith antibiotics to treat for example, acute otitis media with purulentmiddle ear effusion. In some embodiments, levocetirizine and montelukastmay be administered without antibiotics to treat chronic middle eareffusion, for example, chronic otitis media. In some embodiments,levocetirizine and montelukast may be administered with other treatmentmodalities such as, but not limited to, steroids and/or antiviralagents.

Several embodiments relate to the use of a combination of levocetirizineand montelukast to treat allergic fungal rhinosinusitis (AFRS). In someembodiments, levocetirizine and montelukast may be administered withother treatment modalities such as, but not limited to, steroids and/oran antifungal agent.

Intravenous therapy of levocetirizine and montelukast, the lattercurrently under investigation in the United States, would enhance theindividual and combined clinical response presently seen with theadministration of oral medication. The IV montelukast plasmaconcentration area under the curve profile, 7 mg, is comparable to theapproved 10 mg oral montelukast tablet. The former has been shown inacute asthmatics to significantly improve FEV1 (forced expiratory volumeat one sec) at 10 minutes when compared with placebo.

Accordingly, the dosing for acute inflammation could be daily asdelineated above individually in the same setting, as a dual-layertablet(s), and/or as a blister pack containing both medications for a 10day course of therapy. For a moderate to severe clinical presentation,the levocetirizine component can be given at time zero (5 mg), 12 hours(5 mg) and 24 hours (5 mg), during the first 24 hour day, in order toachieve a steady state level of the molecule in less than 40 hours.Levocetirizine human dosing safety studies have been performed at up to30 mg/day. Sedation is the principal side effect experienced at higherdoses. Independent research has shown that levocetirizine alone can bedosed at 20 mg/day to treat severe cases of idiopathic urticaria.

The application for the combination of levocetirizine and montelukastincludes, but is not limited to treating, ameliorating, or preventingthe following symptoms. For influenza, the combination can be useful toshorten the course of seasonal flu and prevent or minimize thedevelopment of lower respiratory tract infections/complications, and/orto establish an improved, safe, world-wide protocol for influenza priorto the next pandemic, e.g., H5N1 with its associated 50% mortality rate.For upper respiratory tract infections, not limited to rhinovirus, thecombination can be useful to limit the infection itself, and/or toprevent or reduce the potential development of secondary sinusitis,bronchitis and pneumonia. The combination can be useful for treatment ofEbstein-Barr Virus, particularly, but not limited to those patients withrespiratory involvement.

For acute asthma in conjunction with existing protocols, not limited toexacerbations caused by rhinovirus (˜50% of cases), the combination canbe useful to shorten the course of the event, reduce hospitalizationsand death. The combination can be useful for pre-treatment of patientsallergic to one or more classes of antibiotics requiring antimicrobialtherapy. These patients are at risk, 4-10× over the general population,of developing a subsequent ALE (allergic-like event). For patients withmoderate to severe life-threatening disease requiring dual/tripleantibiotics, the combination can be useful to reduce the probability ofdeveloping a side-effect(s) from the primary treatment medications. Thecombination can be useful during and following radiation therapy toameliorate the inflammatory response. The combination can be useful forpatients requiring steroids for the treatment of inflammation who areotherwise at increased risk for the development of steroid inducedcomplications. Examples include but are not limited to the following: i)A severe insulin dependent diabetic with an infection such as facialparalysis, and ii) Patient with latent Tuberculosis. For patients onantiviral medication for acute disease, the combination can be used toprevent complications related to the medication(s) as well ascomplications associated with the disease process itself. Thecombination can be used to treat serum sickness, with or withoutsteroids. For pre-treatment of patients on immunotherapy, thecombination can be used to prevent or ameliorate the risk of a systemicreaction. Examples of high risk patients with the potential to develop alife-threatening, systemic event include but are not limited to severeasthmatics, those patients with a concurrent respiratory tractinfection, and those patients with a prior history of a systemicreaction. For pre and intra-treatment of those patients on chemotherapy,the combination can be used to ameliorate side effects associated withthe administration of chemotherapeutic drug(s). For patients exhibitinga transfusion reaction, the combination can be used to limit the sideeffects/life threatening event during the initial reaction and inpreparation for any requisite subsequent transfusion.

As will be readily apparent to one skilled in the art, the useful invivo dosage of levocetirizine and montelukast to be administered and theparticular mode of administration will vary depending upon the age,weight, medical condition of the patient, the severity of the conditionto be treated, the route of administration, the renal and hepaticfunction of the patient, and mammalian species treated, the particularcompounds employed, and the specific use for which these compounds areemployed. The determination of effective dosage levels, that is thedosage levels necessary to achieve the desired result, can beaccomplished by one skilled in the art using routine pharmacologicalmethods. Typically, human clinical applications of products arecommenced at lower dosage levels, with dosage level being increaseduntil the desired effect is achieved. Advantageously, compounds of thepresent embodiments may be administered, for example, in a single dailydose, or the total daily dosage may be administered in divided doses oftwo, three or four times daily.

TABLE VI TREATMENT PROTOCOL FOR ACUTE INFLAMMATION NOT LIMITED TOINFLUENZA AND THE COMMON COLD Levocetirizine - US Adults: 5 mg/dayChildren: 6-11 years of age: 2.5 mg/day Children: 6 months to 5 years1.25 mg/day Montelukast - US Adults: 10 mg orally/day Children 6-14years of age: 5 mg orally/day Children 6 months-5 years of age: 4 mgorally/day

Depending upon the severity of the acute process, the doses in Table VIcan be modified. For example, the age appropriate dose forlevocetirizine may be given at time zero (at presentation) with anadditional age appropriate dose at 12 hours. In order to protect thelower airway, particularly in the face of bronchitis/pneumonia, a doseof montelukast may be given at time zero (at presentation) with anadditional age appropriate dose of montelukast at 12 hours. In thisfashion the steady state level of the two drugs would approach 24 hours.Montelukast, like levocetirizine, is considered a very safe molecule.Montelukast has been administered at doses up to 200 mg/day (20× thestandard adult daily dose) to adult patients for 22 weeks and inshort-term studies, up to 900 mg/day (90× the standard adult daily dose)to patients for approximately one week without clinically importantadverse events. Dosing duration may parallel the generally acceptedprotocols for their respective disease states. For example, conventionaltherapy for an acute infectious disease process is typicallyadministered for 5-14 days. A course of combined levocetirizine oncedaily plus montelukast once daily may be given for the same duration.For the treatment of chronic inflammatory disease states, an ageappropriate once daily dosing of each medication may also beadministered.

Brain Injuries

Hypoxic-ischemic brain injury is a general classification of braininjury which includes in part, brain trauma, cardiac arrest, vascularcatastrophe (hemorrhagic, thrombotic stroke), and poisoning (such ascarbon monoxide or drug overdose) and central nervous system infection.Improved techniques have resulted in greater numbers of patientssurviving with variable degrees of brain injury. The evolution ofhypothermic treatment has been particularly useful in improvingneurologic morbidity and decreasing mortality in survivors of cardiacarrest and major brain trauma. The induction of mild to moderatehypothermia to a target temperature of 32-34° C. has improved theneurologic outcomes; however, refinement of existing protocols withvalidated studies are needed.

Supportive and preventive care measures remain the mainstay of therapyin all forms of hypoxic-ischemic brain injury. In additions to concertedefforts to restore the central nervous system to its pre jury state,clinicians are additionally focused on preventing nosocomial infection,providing adequate nutrition and providing adequate prophylaxis againstvenous thromboembolism, and gastric stress ulceration.

Severe traumatic brain injury is defined as head trauma associated witha Glasgow Coma Scale (GCS) score of 3-8. The GCS ranges from 3-15 and isan assessment tool used by emergency medical providers to objectivelyprovide a degree of consciousness. The following equation is used:E+M+V=3 to 15; FIG. 6 provides a definition for each of these variables.A GCS score greater than or equal to 9 typically indicates that apatient is not in coma. More specifically, a score of 9-11 indicatesmoderate severity, and a score greater than or equal to 12 indicates aminor injury. A GCS score of 8 is thus a critical score: 50% of patientswith a GCS score of less than or equal to 8 at 6 hours die and 90% ofpatients with a GCS score of less than or equal to 8 are in coma.

The estimated cost of treatment for all categories of traumatic braininjury (TBI) is $80 billion per year. TBI is the leading cause ofmortality for Americans between the age of one and forty-five years.Over the past two decades guidelines have evolved to improve injuryoutcomes particularly those endorsed by the World Health OrganizationCommittee in Neurotramatology.

From the contemporary literature, it can be found that traumatic braininjury is divided into two distinct periods: primary and secondary. Theprimary brain injury is the physical damage to the parenchyma (tissue,vessels) that occurs during the traumatic event, e.g., skull fracture,cerebral contusion and hemorrhage.

The secondary injury is the result of a complex process that occurs overthe ensuing hours to days. Numerous secondary brain insults may occur asthe result of intracranial, extracranial, and systemic therapy or thelack thereof. Secondary brain insults, mainly ischemic in nature,include in part, cerebral edema, hematomas, hydrocephalus, intracranialhypertension, vasospasm, metabolic derangement, excitotoxicity, calciumions toxicity, infection, and seizures. Other disorders (for example,bacterial meningitis) can also involve secondary ischemia and thusneuronal injury.

Traditionally, steroids were used in high doses (for example, 24 mgdexamethasone in 24 hours) for the treatment of traumatic brain injuryto decrease the swelling and edema cause by the primary injury (such asskull fracture, cerebral contusion, and hemorrhage). Steroids wereeffective, at least in part, in ameliorating the posttraumatic ischemiaassociated with the release of oxygen free radicals, excitatory aminoacids, cytokines and other inflammatory mediators. In May 2004, a CRASHstudy published data on 10,008 patients that showed the risk of deathfrom all causes within 2 weeks of traumatic brain injury was higher inthe steroid versus placebo groups (21.1% and 17.9%, respectively).Although the rise in risk of death was unclear, a consensus of opinionholds that high-dose steroids increase the risk of secondary infection,gastric ulceration, electrolyte imbalance, fluid retention, and steroidinduced diabetes mellitus. Recent guidelines published by Bullock R. JNeurotrauma. 3. Supple 1. Vol. 24. 2007, pp. S1-S106, hereinincorporated by reference in its entirety, have stated that high-dosemethylprednisolone in the treatment of patients with severe traumaticbrain injury is contraindicated.

In addition, use of glucocorticoids for the treatment of secondaryischemia related to, for example, bacterial meningitis, has beencontroversial. However, some studies have reported that adults receivingdexamethasone for the treatment of bacterial meningitis had a lowerpercentage of unfavorable outcomes, including death, as compared tosubjects who received placebo; in a study of pediatric patients,patients receiving dexamethasone also showed a reduction of meningealinflammation and decreased audiologic and neurologic sequelae ascompared to patients who received placebo. Moreover, patients treatedwith steroids for hemophilus influenza Type B infections have lesslong-term hearing loss than patients treated with antibiotics alone.However, dexamethasone can also decrease antibiotic penetration into thecentral nervous system, and thus the use of steroids can impedeeradication of highly resistant bacterial strains from the cerebralspinal fluid and aggravate neuronal damage in the hippocampal formation.

The administration of levocetirizine and montelukast in combinationexhibits synergistic effects and unexpectedly superior results in thetreatment of brain injuries, particularly traumatic brain injuries.Without being bound to a particularly theory, levocetirizine andmontelukast work to block the H1 and leukotriene receptors,respectively. Thus, levocetirizine and montelukast quickly block therelease of histamine to reduce systemic swelling and improved lungfunction by inhibiting the release of leukotrienes. Furthermore,levocetirizine and montelukast combination synergistically decreaseeosinophil (the white blood cell considered the hallmark ofinflammation) migration and quantity. Moreover, levocetirizine blocksIL-6 (Interleukin 6). As a signaling protein, IL-6 is one of the mostimportant mediators of the acute phase reaction to injury and fever.Importantly, IL-6 is capable of crossing the blood-brain brain barrier,which makes it a significant cytokine even in the presence of a lesssevere, closed head injury.

Autopsy specimens gleaned from the lungs of patients who have died fromARDS, both primarily and secondarily from their trauma, are underscoredby the presence of neutrophils. Levocetirzine additionally blocks IL-8(Interleukin 8), the signaling protein responsible for chemotaxis intarget cells, primarily neutrophils, causing them to migrate to the siteof injury. In addition to neutrophils there are a wide range of othercells, e.g., endothelial cells, mast cells, macrophages, andkeritinocytes that respond to IL-8 as well. Thus, the combination oflevocetirizine and montelukast is expected to decrease morbidity andmortality in patients suffering from traumatic brain injury, increaseresolution of infection and enhance long-term neurological outcomes.

Advantageously, the use of steroids can be avoided. As discussed furtherin Example 1, the combination of levocetirizine and montelukast can alsoenhance a patient's clinical response (foreshortened healing time)following the addition of the combination of levocetirizine andmontelukast to an acute brain trauma protocol. Thus, the combinations oflevocetirizine and montelukast can be used safely in conjunction withmany existing treatment protocols (e.g., acute brain injury, acute lunginjury, acute stroke, meningitis, pneumonia, sepsis). For example,typical antibiotics can be administered to a patient in combination withlevocetirizine and montelukast; such antibiotics include but are notlimited to vancomycin, meropenem, amoxicillin/beta clauvulanic acid,levofloxacin, piperacillin/tazobactam, ceftriaxone, clindamycin,azithromycin, trimethoprim/sulfamethoxazole, doxycycline or combinationsthereof. Additional agents also include, but are not limited to, thebroad spectrum of antibiotics, antivirals, anti-parasitics andantifungals. Moreover, given the excellent safety profiles of bothlevocetirizine and montelukast, the combination can be administered withmany common classes of medications used in an intensive care, hospitalor outpatient setting, including but not limited to the vasopressors,diuretics, anticoagulants, anti-seizure medications, proton pumpinhibitors, glucocorticoids (if necessary), H2 receptor antagonists,antipyretic agents, anti-inflammatories and anti-neoplastic drugs. Thereare very few acute/critical care medications that would pose a majortreatment problem (e.g. significant drug interaction) other than a doseadjustment to allow for underlying liver or kidney failure.

The combination of levocetirizine and montelukast may be administered tothe patient by one or more of the routes, such as enteral,intraperitoneal, inhalation, intramuscular, subcutaneous and oral.Furthermore, the combination of levocetirizine and montelukast may beadministered intravenously, for example, to quickly deliver thecombination as a dual emergency medication, thereby eliciting an evenmore robust response.

As will be readily apparent to one skilled in the art, the useful invivo dosage of levocetirizine and montelukast to be administered and theparticular mode of administration will vary depending upon the age,weight, medical condition of the patient, the severity of the conditionto be treated, the route of administration, the renal and hepaticfunction of the patient, and mammalian species treated, the particularcompounds employed, and the specific use for which these compounds areemployed. The determination of effective dosage levels, that is thedosage levels necessary to achieve the desired result, can beaccomplished by one skilled in the art using routine pharmacologicalmethods. Typically, human clinical applications of products arecommenced at lower dosage levels, with dosage level being increaseduntil the desired effect is achieved. Advantageously, compounds of thepresent embodiments may be administered, for example, in a single dailydose, or the total daily dosage may be administered in divided doses oftwo, three or four times daily.

Lung Injuries

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS)were defined by a panel of experts in 2011 (an initiative of theEuropean Society of Intensive Care Medicine endorsed by the AmericanThoracic Society and the Society of Critical Care Medicine) as theBerlin Definition. Presently there are three stages: mild, moderate, andsevere with an associated increased mortality (27%; 95% CI, 24%-30%;32%; 95% CI, 29%-34%; and 45%; 95% CI, 42%-48%, respectively; P<0.001)and increased median duration of mechanical ventilation in survivors (5days; interquartile [IQR], 2-11; 7 days; IQR, 4-14; and 9 days; IQR,5-17, respectively; P<0.001). The definition was empirically evaluatedusing patient-level meta-analysis of 4188 patients with ARDS from 4multicenter clinical data sets and 269 patients with ARDS from 3single-center data sets containing physiologic information. Thecategories of ARDS are based on the degree of hypoxemia determined bythe ratio of PaO2/FiO2 where the PaO2 is the partial pressure of oxygenin arterial blood and the FiO2 is the fraction of inspired oxygen. Inparticular, the categorization is as follows: (1) Mild ARDS: 200 mmHg<PaO2/FiO2 and less than or equal to 300 mm Hg; (2) Moderate ARDS: 100mm Hg<PaO2/FiO2 and less than or equal to ≤200 mm Hg; and (3) SevereARDS: PaO2/FiO2 is less than or equal to 100 mm Hg. Table VII shows thecomplete Berlin Definition of Acute Respiratory Distress Syndrome.

TABLE VII BERLIN DEFINITION OF ACUTE RESPIRATORY DISTRESS SYNDROME AcuteRespiratory Distress Syndrome Timing Within 1 week of a known clinicalinsult or new or worsening respiratory symptoms Chest imaging^(a)Bilateral opacities - not fully explained by effusions, lobar/lungcollapse, or nodules Origin of edema Respiratory failure not fullyexplained by cardiac failure or fluid overload Need objective assessment(eg, echocardiography) to exclude hydrostatic edema if no risk factorpresent Oxygenation^(b) Mild 200 mmHg < PaO₂/FiO₂ ≤ 300 mmHg with PEEPor CPAP ≥5 cm H₂O^(c) Moderate 100 mmHg < PaO₂/FiO₂ ≤ 200 mmHg with PEEP≥5 cm H₂O Severe PaO₂/FiO₂ ≤100 mmHg with PEEP ≥5 cm H₂O Abbreviations:CPAP, continuous positive airway pressure: FiO₂, fraction of inspiredoxygen; PaO₂, partial pressure of arterial oxygen; PEEP, positiveend-expiratory pressure. ^(a)Chest radiograph or computed tomographyscan. ^(b)If altitude is higher than 1000 m, the correction factorshould be calculated as follows: [PaO₂/FiO₂ × (barometricpressure/760)]. ^(c)This may be delivered noninvasively in the mildacute respiratory distress syndrome group.

Data suggest that this common ICU problem complicating a spectrum ofcritical illnesses is an estimated 190,000 cases in the United Statesper year. Whereas healthy lungs regulate the fluid to maintain a smallamount of interstitial fluid and dry alveoli, lung injury causes excessfluid in both the interstitium and alveoli. The consequences of injuryinclude in part, impaired gas exchange, decreased lung compliance, andincreased pulmonary arterial pressure.

The causes of ARDS have been enumerated at more than 60 with the mostcommon being: sepsis, aspiration, pneumonia, severe trauma (bilaterallung contusion, fat embolism after long bone fracture, sepsis thatdevelops several days after severe trauma or burns, and massivetraumatic tissue injury), massive transfusion, transfusion related acutelung injury, lung and hematopoietic stem cell transplantation, drugs andalcohol, and genetic determinants such as mutations in the surfactantprotein B (SP-B) gene.

The pathophysiology is complex and remains incompletely understood.Neutrophils play an important role in the initial inflammatory response.Early ALI/ARDS is characterized by migration of neutrophils into thealveolar compartment which in turn release injurious substances such aproteases and gelatinases A and B.

Clinically the acute phase is depicted by the onset of radiographicinfiltrates, consistent with pulmonary edema, hypoxemia and increasedwork of breathing. A late phase apparent after seven to 10 days ischaracterized by fibrosing alveolitis. Radiographically, linearopacities develop underscored by airspaces filled with granulationtissue. Characteristically there is a need for continued mechanicalventilation with high levels of PEEP (positive end expiratory pressure)and high levels of inspired oxygen (FiO2).

Management of ARDS (Table VIII) includes treatment of the underlyingcondition, mechanical or noninvasive ventilation, fluid and hemodynamictherapy, treatment of opportunistic infection, nutrition, andpharmacologic therapy. Currently there is no specific pharmacologictherapy for ALI/ARDS. Agents that have failed in large trials include inpart, glucocorticoids, alprostadil, surfactant, ketoconazole,N-acetylcysteine, procysteine, lisofylline, and site-inactivatedrecombinant factor VIIa. Given the concern for the increased risk ofnosocomial infection or critical illness polyneuropathy, as well as thelack of improvement in mortality, the routine use of glucocorticoids inARDS is not recommended.

TABLE VIII MANAGEMENT OF PATIENTS WITH ARDS Calculate Predicted BodyMales: PBW (kg) = 50 + 2.3[(height in inches) − 60] or 50 + Weight (PBW)0.91[(height in cm) − 152.4]. Females: IBW (kg) = 45.5 + 2.3[(height ininches) − 60] or 45.5 + 0.91[(height in cm) − 152.4]. Ventilator ModeVolume assist/control until weaning. Tidal Volume (V_(T)) Initial V_(T):6 mL/kg predicted body weight. Measure inspiratory plateau pressure(Pplat, 0.5 sec inspiratory pause) every 4 hours AND after each changein PEEP or V_(T). If Pplat > 30 cm H₂O, decrease V_(T) to 5 or to 4mL/kg. If Pplat < 25 cm H₂O and V_(T) < 6 mL/kg PBW, increase V_(T) by 1ml/kg PBW. Respiratory Rate (RR) With initial change in V_(T), adjust RRto maintain minute ventilation. Make subsequent adjustments to RR tomaintain pH 7.30- 7.45, but do not exceed RR = 35/min, and do notincrease set rate if Pa_(CO) ₂ < 25 mm Hg. I:E Ratio Acceptable range =1:1 to 1:3 (no inverse ratio). F_(IO) ₂ , Positive End- Maintain Pa_(O)₂ = 55-80 mm Hg or Sp_(O) ₂ = 88%-95% using the Expiratory Pressure(PEEP), following PEEP/F_(IO) ₂ combinations: and Arterial OxygenationF_(IO) ₂ 0.3-0.4 0.4 0.5 0.6 0.7 0.8 0.9 1 PEEP 5-8 8-14 8-16 10-2010-20 14-22 16-22 18-25 Acidosis Management If pH < 7.30, increase RRuntil pH ≥ 7.30 or RR = 35/min. If pH remains < 7.30 with RR = 35,consider bicarbonate infusion. If pH < 7.15, V_(T) may be increased(Pplat may exceed 30 cm H₂O). Alkalosis Management If pH > 7.45 andpatient not triggering ventilator, decrease set RR but not below 6/min.Fluid Management Once patients are out of shock, adopt a conservativefluid management strategy. Use diuretics or fluids to target a centralvenous pressure (CVP) of <4 or a pulmonary artery occlusion pressure(PAOP) of <8. Liberation from Mechanical Daily interruption of sedation.Ventilation Daily screen for spontaneous breathing trial (SBT). SBT whenall of the following criteria are present: (a) F_(IO) ₂ < 0.40 and PEEP< 8 cm H₂ _(O.) (b) Not receiving neuromuscular blocking agents. (c)Patient awake and following commands. (d) Systolic arterial pressure >90 mm Hg without vasopressor support. (e) Tracheal secretions areminimal, and the patient has a good cough and gag reflex. SpontaneousBreathing Trial Place patient on 5 mm Hg pressure support with 5 mm HgPEEP or T-piece. Monitor HR, RR, oxygen saturation for 30-90 minutes.Extubate if there are no signs of distress (tachycardia, tachypnea,agitation, hypoxia, diaphoresis).

The use of levocetirizine plus montelukast fills an unmet need in thisarea of critical care medicine. Without being bound to a particulartheory, levocetirizine is not only an effective antihistamine but alsoacts at physiologic doses to block IL-8 (Interleukin-8). 11-8 is thesignaling protein (chemokine) which regulates the influx of neutrophilswitnessed in the acute phase of ALI/ARDS. Moreover, levocetirizineblocks IL-6 (Interleukin-6), the signaling protein which acts as a majormediator of both the acute phase response to injury and fever.Montelukast is a safe, effective leukotriene receptor antagonist andblocks the action of LTD4, the most potent of the cysteinyl leukotrienesin contracting smooth airway muscle. Given orally or intravenously, a15% improvement in the FEV1 (forced expiratory volume at 1 sec) can berealized in minutes to hours as shown in FIG. 7.

Without being bound to a particular theory, both molecules actsynergistically to decrease eosinophil quantity and/or migration, wherethe eosinophil is considered the hallmark of the inflammation. AsPregnancy Category B medications, the combination of levocetirizine plusmontelukast can be used safely in a myriad of ICU clinical settings toaugment existing treatment protocols, thereby decreasingmorbidity/mortality.

As discussed further in Example 2 below, the combination oflevocetirizine and montelukast will decrease the requirement foroperative procedures such as bronchoscopy and tracheotomy byfacilitating early extubation. This in turn will lead to a reduction incomplications commonly found in the Intensive Care Unit, e.g.,nosocomial infection, pneumothorax secondary to mechanical ventilation,thromboemboli, secondary bleeding, stress and decubitus ulcers.Foreshortened lung and CNS (central nervous system) healing times willeffectively decrease the length of the hospital stays and reduce therequirement for digital imaging and revision surgery in addition to thenonexclusive list of complications previously mentioned. Patients willbenefit from improved lung function and neurological outcomes. Forexample, as shown in example 2, the patient with a closed head injuryand moderate ARDS by international criteria was treated with acombination of levocetirizine plus montelukast via nasogastric tube. Hewas extubated on day 2 and discharged from the hospital on day 4. Thestatistical mean time for intubation alone in this category of lunginjury is 7 days.

Advantageously, the use of glucocorticoids can be avoided. Moreover, thecombinations of levocetirizine and montelukast can be used safely inconjunction with many existing treatment protocols (e.g., acute braininjury, acute lung injury, acute stroke, meningitis, pneumonia, sepsis).For example, typical antibiotics can be administered to a patient incombination with levocetirizine and montelukast; such antibioticsinclude but are not limited to vancomycin, meropenem, amoxicillin/betaclauvulanic acid, levofloxacin, piperacillin/tazobactam, ceftriaxone,clindamycin, azithromycin, trimethoprim/sulfamethoxazole, doxycycline orcombinations thereof. Additional agents would also include, but are notlimited to, the broad spectrum of antibiotics, antivirals,anti-parasitics and antifungals. Moreover, given the excellent safetyprofiles of both levocetirizine and montelukast, the combination can beadministered with many common classes of medications used in anintensive care, hospital or outpatient setting, including but notlimited to the vasopressors, diuretics, anticoagulants, anti-seizuremedications, proton pump inhibitors, glucocorticoids (if necessary), H2receptor antagonists, antipyretic agents, anti-inflammatories andanti-neoplastic drugs. There are very few acute/critical caremedications that would pose a major treatment problem (e.g. significantdrug interaction) other than a dose adjustment to allow for underlyingliver or kidney failure.

The combination of levocetirizine and montelukast may be administered tothe patient by one or more of the routes, such as enteral,intraperitoneal, inhalation, intramuscular, subcutaneous and oral.Furthermore, the combination of levocetirizine and montelukast may beadministered intravenously, for example, to quickly deliver thecombination as an emergency combination.

As will be readily apparent to one skilled in the art, the useful invivo dosage of levocetirizine and montelukast to be administered and theparticular mode of administration will vary depending upon the age,weight, medical condition of the patient, the severity of the conditionto be treated, the route of administration, the renal and hepaticfunction of the patient, and mammalian species treated, the particularcompounds employed, and the specific use for which these compounds areemployed. The determination of effective dosage levels, that is thedosage levels necessary to achieve the desired result, can beaccomplished by one skilled in the art using routine pharmacologicalmethods. Typically, human clinical applications of products arecommenced at lower dosage levels, with dosage level being increaseduntil the desired effect is achieved. Advantageously, compounds of thepresent embodiments may be administered, for example, in a single dailydose, or the total daily dosage may be administered in divided doses oftwo, three or four times daily.

Definitions

The term “effective amount” includes an amount effective, at dosages andfor periods of time necessary, to achieve the desired result, e.g.,sufficient to treat lung and/or brain injuries. An effective amount oflevocetirizine and montelukast may vary according to factors such as thedisease state, age, and weight of the subject, and the ability oflevocetirizine and montelukast to elicit a desired response in thesubject. Dosage regimens may be adjusted to provide the optimumtherapeutic response. An effective amount is also one in which any toxicor detrimental effects (e.g., side effects) of levocetirizine andmontelukast are outweighed by the therapeutically beneficial effects.

“Ameliorate,” “amelioration,” “improvement” or the like refers to, forexample, a detectable improvement or a detectable change consistent withimprovement that occurs in a subject or in at least a minority ofsubjects, e.g., in at least about 2%, 5%, 10%, 15%, 20%, 25%, 30%, 40%,50%, 60%, 70%, 75%, 80%, 85%, 90%, 95%, 98%, 100% or in a range betweenany two of these values. Such improvement or change may be observed intreated subjects as compared to subjects not treated with levocetirizineand montelukast, where the untreated subjects have, or are subject todeveloping, the same or similar disease, condition, symptom or the like.Amelioration of a disease, condition, symptom or assay parameter may bedetermined subjectively or objectively, e.g., self assessment by asubject(s), by a clinician's assessment or by conducting an appropriateassay or measurement, including, e.g., a quality of life assessment, aslowed progression of a disease(s) or condition(s), a reduced severityof a disease(s) or condition(s), or a suitable assay(s) for the level oractivity(ies) of a biomolecule(s), cell(s), by detection of respiratoryor inflammatory disorders in a subject, and/or by modalities such as,but not limited to photographs, video, digital imaging and pulmonaryfunction tests. Amelioration may be transient, prolonged or permanent orit may be variable at relevant times during or after levocetirizine andmontelukast are administered to a subject or is used in an assay orother method described herein or a cited reference, e.g., withintimeframes described infra, or about 1 hour after the administration oruse of levocetirizine and montelukast to about 28 days, or 1, 3, 6, 9months or more after a subject(s) has received such treatment.

The “modulation” of, e.g., a symptom, level or biological activity of amolecule, or the like, refers, for example, to the symptom or activity,or the like that is detectably increased or decreased. Such increase ordecrease may be observed in treated subjects as compared to subjects nottreated with levocetirizine and montelukast, where the untreatedsubjects have, or are subject to developing, the same or similardisease, condition, symptom or the like. Such increases or decreases maybe at least about 2%, 5%, 10%, 15%, 20%, 25%, 30%, 40%, 50%, 60%, 70%,75%, 80%, 85%, 90%, 95%, 98%, 100%, 150%, 200%, 250%, 300%, 400%, 500%,1000% or more or within any range between any two of these values.Modulation may be determined subjectively or objectively, e.g., by thesubject's self-assessment, by a clinician's assessment or by conductingan appropriate assay or measurement, including, e.g., quality of lifeassessments, suitable assays for the level or activity of molecules,cells or cell migration within a subject and/or by modalities such as,but not limited to photographs, video, digital imaging and pulmonaryfunction tests. Modulation may be transient, prolonged or permanent orit may be variable at relevant times during or after levocetirizine andmontelukast are administered to a subject or is used in an assay orother method described herein or a cited reference, e.g., within timesdescribed infra, or about 1 hour after the administration or use oflevocetirizine and montelukast to about 3, 6, 9 months or more after asubject(s) has received levocetirizine and montelukast.

As used herein, the terms “prevent,” “preventing,” and “prevention”refer to the prevention of the recurrence, onset, or development of lungand/or brain injury. Preventing includes protecting against theoccurrence and severity of upper and/or lower respiratory tractinfections.

As used herein, the term “prophylactically effective amount” refers tothe amount of a therapy (e.g., a pharmaceutical composition comprisingmontelukast and levocetirizine) which is sufficient to result in theprevention of the development, recurrence, or onset of lung and/or braininjury or to enhance or improve the prophylactic effect(s) of anothertherapy.

As used herein, “subject” includes organisms which are capable ofsuffering from lung and/or brain injury or other disorder treatable by acombination of montelukast and levocetirizine or who could otherwisebenefit from the administration of montelukast and levocetirizine asdescribed herein, such as human and non-human animals. Preferred humananimals include human subjects. The term “non-human animals” includesall vertebrates, e.g., mammals, e.g., rodents, e.g., mice, andnon-mammals, such as non-human primates, e.g., sheep, dog, cow,chickens, amphibians, reptiles, etc.

The following Examples are presented for the purposes of illustrationand should not be construed as limitations.

EXAMPLES Example 1

Case Study: 18-year-old male trauma patient with brain, lung, facial andliver injuries

Patient CR DOB Jun. 14, 1993 Age 18

The patient is a 18-year-old male seen and evaluated in the SantaBarbara Cottage Hospital Surgical ICU after falling off a cliff in IslaVista, Calif. at approximately midnight 02/17/2012. The estimated heightof the fall was 30-35 feet. His Glasgow Coma scale on admission was7/15, reflecting a greater than fifty percent chance of mortality.Contributing factor: alcohol with the consumption of 10 drinks between 9PM and midnight. (BAC 0.252 g/dL).

Social History: student at the University of California, Santa Barbara

Pre-existing Major Medical Problems: none

Pertinent Physical Examination:

At the time of the consultation, Saturday 02/18/2012 (10:30-13:15 hours)CR was intubated and sedated on a ventilator.

Vital signs: Temperature 36.9° C. B/P 95/39 mm Hg Pulse 76 beats/minRespiratory rate controlled 20/minute

Tidal volume 500 ml FiO2 (inspired oxygen) 40%. PEEP: 5 cm H2O

Weight: 73 kg Height: 177.8 cm

HEENT:

Ears: gray tympanic membranes, no hemotympanum noted Nose:serosanguinous drainage right. Laceration of the right nasolabialgroove - sutured Throat: intubated Eyes: right upper lid ecchymosisFace: equivocal depression of the right cheek Lungs: decreased breathsounds in the right lower lung field Heart: S1, S2 distinct, nopathological murmur

Laboratory Data:

02/18/2012 at 11:13 hours

Arterial blood gases: pH 7.28, PaO2 129 mm Hg, FiO2 0.40, PaCO2 41 mm Hg

WBC: 19,100 cells/μL, hemoglobin 11.8 g/dL, hematocrit 33.3%,

platelet count 253,000/μL

BAC (blood alcohol content) 0.252 g/dLat 12:40 hours

PT 12.8 sec., PTT 30.1 sec. at 04:55 hours

sodium 139 mEq/L, potassium 4.0 mEq/L, chloride 109 mEq/L,

bicarbonate 19 mEq/L, BUN 17 mg/dL, creatinine 0.83 mg/dL

Imaging: Reviewed with Radiology: Hospital Day #1

CT Scan of the head without contrast 01:10, 02/18/2012: Contusions ofthe frontal lobes with punctate hemorrhages, right greater than left.

CT Scan of the face 01:10, 02/18/2012: multiple comminuted fractures

Nasal bones

Right maxillary sinus with fat herniating from the right orbit into theethmoid sinus, as well as inferiorly into the maxillary sinus, i.e.,blowout fracture ˜1.25 cm

Fracture of the lateral and medial walls of the right maxillary sinus;nondisplaced fracture of the right zygoma.

CT Scan of the chest, abdomen and pelvis: 01:18 hours, 02/18/2012:compatible with aspiration pneumonia, right greater than left, i.e.,dense consolidations within the dependent portions of the lungs rightgreater than left and ground glass opacities within the anterior aspectsof the lungs bilaterally as well as debris seen within the distalbronchioles consistent with aspiration

Abdomen and pelvis: questionable focal laceration of the lateral lobe ofthe liver

Neck: no fractures delineated. Straightening of the usual cervicallordosis

Assessment: 18 year old male status post ˜30-35 foot fall from a cliffin Isla Vista, Ca. just before midnight, 02/17/2012.

Multiple facial fractures as delineated

Frontal lobe contusions of the brain, right greater than left

Aspiration pneumonia, right greater than left

Focal laceration of the right lobe of the liver Treatment Regimen:

Trauma Protocol for severe brain injury: Induced coma with externalventricular drain Licox (brain tissue oxygen) monitoring Intravascularcentral cooling catheter Prophylactic antibiotic coverage to vancomycinand meropenem include: to cover opportunistic pathogens associated withthe brain, lung and facial injuries Levocetirizine 5 mg per nasogastrictube/ abort the inflammatory orally every 12 hours × 2, then every 24response in the brain and face hours plus montelukast 10 mg per addressthe acute lung injury nasogastric tube/orally every 12 hours × 2,without the use of steroids. then every 24 hours initiated Feb. 19, 2012(hospital day #2) through Mar. 4, 2012 (hospital #16: 15 days oftherapy)

Steroids in this critical care setting have been correlated with anincreased risk of secondary infection with an associated increase inmorbidity and mortality.

Clinical Course (Lung):

The patient underwent two bedside bronchoscopies, the first of whichonly identified thick secretions in the lower airway the evening of02/19/2012, hospital day #2. Increasing deterioration with an associatedPaO2/FiO2 of 247.4 (Berlin definition of mild ARDS) led to theadministration of levocetirizine and montelukast therapy via nasogastrictube the evening of 02/19/2012, hospital day #2.

A CT scan of the patient's chest (depicted in FIG. 2A) taken at 09:30hours, 02/21/2012, hospital day #4, 36 hours into therapy, revealed: (1)a patchy infiltrate in the right upper lobe with a multinodularappearance and denser consolidation in the right lower lobe, suggestingmultifocal pneumonia. Aspiration could not be ruled out. (2) Noted aswell were small bilateral pleural effusions, right greater than leftwith (3) consolidation in the posterior left lower lobe indicatingatelectasis or a third area of pneumonia. There was no CT evidence ofpulmonary embolism. Armed with this data, a second bronchoscopy wasperformed on 02/21/2012, hospital day #4, which identified and extractedsignificant food foreign bodies, particularly in the right mainstembronchus. Thereafter, the patient rapidly improved as predicted underthe umbrella of levocetirizine plus montelukast and was extubated at09:30 hours, 02/23/2012, hospital day #6.

A follow-up chest x-ray on 02/25/2012, hospital day #8 (depicted in FIG.3) demonstrated nearly resolved bibasilar opacities (and thus likelyreflecting volume loss) with no blunting of the costophrenic angles(otherwise reflecting fluid or atelectasis). The x-ray also showed nonew infiltrate, effusion, or congestive heart failure. The leftsubclavian line remained in place.

The rapid resolution of the aspiration pneumonia was aided by the use oflevocetirizine plus montelukast (significantly shorter clearing time byseveral days when compared to conventional therapy, i.e., almostcomplete clearing between day #4, the day of the foreign body removaland day #8) using imaging as an objective marker. No additionalpulmonary intervention was required during the hospitalization.

Clinical Course (Brain):

The patient was weaned from sedation on 02/22/2012, post injury day #4.A CT scan of the patient's brain, taken 0243 hours, 02/22/2012, (asshown in FIG. 2B) demonstrated the following: (1) slight intervalimprovement of the multiple nodular densities throughout the frontallobes, bilaterally consistent with parenchymal contusions; stablecerebral edema within the inferior frontal lobes bilaterally; (2) stableright frontal approach ventriculostomy catheter tip in the right lateralventricle and pressure monitor within the right frontal lobe; (3)multiple facial fractures as better seen on prior CT Scan of the face;and (3) stable paranasal sinuses.

The findings reflect an enhanced clinical response (foreshortenedhealing time) in less than 2.5 days following the addition oflevocetirizine+montelukast (02/19/2012 PM, hospital day #2) to the braintrauma protocol. An even more robust response would be realized from thecombination of IV levocetirizine+montelukast (currently not available)given on presentation to the Emergency Room (time zero).

The patient was extubated at 09:30 hours, 02/23/2012 post injury day #5despite the aspiration and two bronchoscopies. He emerged from the coma,was stabilized and was transferred 03/02/2012, hospital day #14 to theCottage Rehabilitation Hospital at essentially a Rancho 4 level ofcognitive function. Maxillofacial fractures were corrected on 03/01/2012prior to transfer. He was discharged 03/14/2012 to his parents fortravel home to the East Coast.

On admission to Cottage Rehabilitation Hospital, CR's functional statusshowed him to be supervised for feeding. Grooming was minimallyassisted. Bathing was minimally assisted. Upper and lower body dressingwere supervised. He was able to manage his own bowel and bladder, butdid require supervision due to some impulsivity. He was supervised fortransfers. He was rather impulsive and had a strong drive to continueambulating. It was very difficult for him to sit down and relax. He didcomplain of diplopia on admission, but this improved throughout thecourse of the hospitalization. His memory was moderately impaired as wasdecision-making and problem-solving. Initially he had very poor memoryand poor carryover from session to session and day-to-day.

By discharge, he required minimal prompting for memory and minimaldirection for problem-solving. Social interactions were modifiedindependent.

A telephone discussion with both parents on 05/08/2012 confirmed theirson was doing well and would return to both school and sports in thefall of 2012.

Overview:

This case is a clinical example of the remarkable anti-inflammatorysynergy between two extremely safe molecules: levocetirizine plusmontelukast for the treatment of acute lung and brain injury. There wereno complications from twice daily and daily dosing administered duringthe initial fifteen day period of his hospital/rehabilitation stay.

Example 2

Case Study: 19 year old male with aspiration pneumonia/pulmonarycontusion/closed head injury

Patient EL DOB Aug. 14, 1993 Age 19

The patient is a 19 year old male status post 20 foot fall from abuilding in Isla Vista, Calif. at 01:00 hours, Sunday, 10/28/2012, withresultant significant mid-facial fractures, lung contusion, aspirationand closed head injury. The Glasgow Coma Scale as an index ofconsciousness at the scene was 3/15 (normal 15/15). He had nospontaneous movement and appeared to have severe facial trauma. EL wassubsequently transported via ambulance to the Santa Barbara CottageHospital Emergency Room for evaluation and admission. At the time of theinitial Otolaryngology evaluation he was intubated on a respirator inthe SICU (Surgical Intensive Care Unit). Respirator settings were asfollows: FIO2 60% (inspired oxygen), PEEP five cm H2O, tidal volume 500ml, SMIV, pressure support 10 cm H2O

Vital signs: Temperature 100.5° F./38.1° C. Heart rate 114 beat/min

Respiratory rate 29-32 breaths/minute B/P 117/50 mmHg

Weight 58 kg Height 167 cm BMI 24.2

HEENT:

Ears AS (left): gray tympanic membrane, AD (right): scant hemotympanumNose occlusion of the left anterior airway from swelling of the leftinferior turbinate and deviated nasal septum. Throat endotracheal tubeand orogastric tube in place Neck without adenopathy Lungs Bilateralrhonchi Heart tachycardia/regular rhythm Abdomen flat NeuroIntubated/sedated

Preadmission medications: none

Past surgical history: none

Major medical problems: none

Social History: student at Cal Lutheran

Allergies to Medication: none

Laboratory Data: at 0456 hours, 10/28/2012: white count 5000 cells/μL,

hemoglobin 15.1 g/dL, hematocrit 45.3%, platelet count 171,000/μL.troponin less than 0.03 μg/L. sodium 137 mEq/L, potassium 3.3 mEq/L,chloride 106 mEq/L, bicarbonate 22 mEq/L, BUN 11 mg/dL, creatinine 0.7mg/dL, glucose 138 mg/dL. BAC (blood alcohol content) 0.225 g/dL

Arterial blood gases at noon, Sunday, 10/28/2012: FIO2 0.50, pH 7.28,

PaCO2 30 mm Hg, PaO2 68 mm Hg, bicarbonate 14 mEq/L. (Berlin definitionof moderate ARDS—anticipated mean intubation period of 7 days)

Imaging: reviewed with radiology the morning of 10/28/2012:

CT Scan of the Brain and Facial Bones 0152 hours, 10/28/2012:

No acute intracranial pathology identified.

Soft tissue swelling of the right cheek.

Old septal fracture—right.

New comminuted nasoseptal fracture.

Fracture of the right lamina papyracea.

Fracture of the lateral wall of the left maxilla.

Air in the right orbit.

Blood in the nasal airway, ethmoid sinuses, left frontal sinus and leftmaxillary sinus.

C-spine 01:52 hours, 10/28/2012: no fracture.

Chest x-ray 02:50 hours, 10/28/2012: bilateral infiltrates. A secondchest x-ray taken at 0503 hours, 10/28/2012, prior to the initiation oftherapy, is depicted in FIG. 5A.

CT Scan of the chest: 01:59 hours, 10/28/2012: demonstrated bilateralpulmonary contusions/aspiration (as shown in FIG. 4).

X-ray of the pelvis 01:33 hours, 10/28/2012: negative for fracture.

Antibiotics: Vancomycin 1 gram IV q 8 hours, Zosyn®(piperacillin/tazobactam) 3.375 mg IV q 6 hours representing standardtherapy for listed injuries (open facial trauma+aspiration pneumonia)

Plan:

Baseline CRP (C-reactive protein) and SED (sedimentation) Rate

Levocetirizine 5 mg per orogastric tube q 12 hours×2 doses, followed by5 mg q 24 hours×10 days.

Montelukast 10 mg per orogastric tube q 12 hours×2 doses, followed by 10mg q 24 hours

The combination of levocetirizine and montelukast was administered toachieve steady state levels at ˜24 hours (as opposed to ˜40 hours);synergistically block the acute inflammatory response without usingsteroids.

Hospital Course:

The patient made a remarkable recovery on the aforementioned protocol.He was extubated on hospital #2, 10/29/2012, transferred to the floor onhospital day #3, 10/30/2012, and discharged home on day #4, 10/31/2012.Augmentin® (amoxicillin/beta-clavulanic acid) and Levaquin®(levofloxacin) antibiotics were continued on an outpatient basis, aswell as the levocetirizine and montelukast. His nasoseptal fracture wasset in outpatient surgery 11/07/2012. A chest x-ray on 11/5/2012, postinjury day #8, (FIG. 5B) objectively shows the patient's lungs havecleared, demonstrating the resolution of the lung contusion/bilateralpulmonary infiltrates.

Overview:

This case is an example of the remarkable anti-inflammatory synergybetween two extremely safe molecules: levocetirizine plus montelukast inthe treatment of acute lung injury. No interval bronchoscopy was needed,and there were no complications from the major trauma. In addition to aforeshortened lung recovery time (8 days) as opposed to two to threeweeks, the lungs cleared without bronchoscopic intervention forculture/debridement and there were no complications in this criticallyill patient.

The patient was extubated hospital day #2 and discharged hospital day#4. The mean intubation time alone for moderate ARDS as delineated bythe Berlin definition is 7 days with an associated risk of mortality of32%.

Example 3

Prophetic Study: Patients with mild, moderate, and severe AdultRespiratory Distress Syndrome.

In this study, the combination of levocetirizine and montelukast isadministered to patients suffering from mild Adult Respiratory DistressSyndrome (ARDS), patients suffering from moderate ARDS, and patientssuffering from severe ARDS. The following particular parameters aremonitored: length of hospital stay, number of days on a ventilator(intubated), mortality, and secondary infection. All patients are giventhe combination of levocetirizine and montelukast upon presentation.Given the intrinsic safety of the molecules and synergistic manner inwhich multiple pathways are blocked during the acute or innate phaseresponse to trauma, an initial group of 20 patients are compared withretrospective data gleaned from patients treated with existingprotocols.

Anticipated Outcomes Include the Following:

Reduced intubation time when compared to patients exhibiting the same orsimilar degrees of injury and the same Berlin classification;

Reduced length of hospital stay;

Decreased mortality; and

Decreased number of nosocomial infections.

The Combination of Levocetirizine and Montelukast

Without being bound to a particular theory, it is believed thatmontelukast alone would improve lung function and potentially decreasetotal intubation times while levocetirizine would not be potent enoughby itself to clear a patient's lungs. However, the combination oflevocetirizine and montelukast exhibits synergy to effectively treatARDS and its related symptoms in the three classes of patientsidentified above (mild, moderate, severe).

The effect can be reasonably extrapolated from the cell science.Levocetirzine blocks the acute or innate phase response to injury notonly as an antihistamine but through its anti-inflammatory propertieswhich include in part, the modulation of toll-like receptors,Interleukin 6 (IL-6) and Interleukin 8 (IL-8). IL-6 is one of the mostimportant mediators of the acute phase reaction to injury and fever.

Moreover, autopsy specimens gleaned from the lungs of patients who havedied from ARDS, both primarily and secondarily from their trauma, areunderscored by the presence of neutrophils. Levocetirzine blocks IL-8,the signaling protein responsible for chemotaxis in target cells,primarily neutrophils, causing them to migrate to the site of injury. Inaddition to neutrophils there are a wide range of other cells, e.g.,endothelial cells, mast cells, macrophages, and keritinocytes thatrespond to IL-8 as well. Montelukast block the actions of LTD4 at thereceptor. Leukotriene D4 is most potent of the cysteinyl leukotrienes incontracting airway smooth muscle. It promotes the recruitment ofeosinophils, dendritic cells (antigen presenting cells) and T cells,which in turn in increases cell recruitment and activation. Clinically,montelukast has been shown to increase FEV1 (forced expiratory volume inthe first second of expiration) by 15% in minutes to hours followingadministration.

Both levocetirizine and montelukast affect eosinophilquantity/migration. An eosinophilic infiltrate is considered a hallmarkof inflammation.

Thus, given the multiple sites of action within the inflammatory pathwayunderscored by the safety of the molecules, the combination oflevocetirizine and montelukast will improve outcomes over existingprotocols, and decrease morbidly and mortality in this patientpopulation.

Example 4

Prophetic Study: Patients with acute brain injury/traumatic brain injury

In this study, the combination of levocetirizine and montelukast isadministered to patients suffering from acute brain injury or patientssuffering from traumatic brain injury.

The following particular parameters are monitored: LICOX (brain tissue02 and temperature data), a neurological baseline assessment andcorresponding data taken after patients have been treated with thecombination of levocetirizine and montelukast for 30 days, the GlasgowComa Scale (statistically significant for mortality in the first twoweeks of hospitalization), APACHE III scores (statistically significantfor mortality after two weeks of hospitalization), length of hospitalstay, number of days on a ventilator (intubated), mortality, andsecondary infection. All patients are given the combination oflevocetirizine and montelukast upon presentation. Given the intrinsicsafety of the molecules and synergistic manner in which multiplepathways are blocked during the acute or innate phase response totrauma, an initial group of 20 patients are compared with retrospectivedata gleaned from patients treated with existing protocols.

Anticipated Outcomes Include the Following:

Improved neurological function using standard measures of cognitivefunction

Reduced intubation time when compared to patients exhibiting the same orsimilar degrees of injury and the same Berlin classification.

Reduced length of hospital stay

Decreased mortality

Decreased number of nosocomial infections

The Combination of Levocetirizine and Montelukast

Without being bound to a particular theory, it is believed thatmontelukast alone would have minimal effect while levocetirizine woulddecrease swelling and limit tissue hypoxia/ischemia. By comparison, thecombination of levocetirizine and montelukast safely exhibits aremarkable synergy to effectively treat acute brain injury or traumaticbrain injury and their related symptoms.

The effect can be reasonably extrapolated from the cell science.Levocetirzine blocks the acute or innate phase response to injury notonly as an antihistamines but through its anti-inflammatory propertieswhich include in part, the modulation of toll-like receptors, IL-6 andIL-8. IL-6 is one of the most important mediators of the acute phasereaction to injury and fever. Importantly, IL-6 is capable of crossingthe blood-brain brain, which makes it a significant cytokine even in thepresence of a less severe, closed head injury.

Autopsy specimens gleaned from the lungs of patients who have died fromARDS, both primarily and secondarily from their trauma, are underscoredby the presence of neutrophils. Levocetirzine additionally blocks IL-8(Interleukin 8), the signaling protein responsible for chemotaxis intarget cells, primarily neutrophils, causing them to migrate to the siteof injury. In addition to neutrophils there are a wide range of othercells, e.g., endothelial cells, mast cells, macrophages, andkeritinocytes that respond to IL-8 as well.

Montelukast block the actions of Leukotriene D4 (LTD4) at the receptor.LTD4 is the most potent of the cysteinyl leukotrienes in contractingairway smooth muscle. It promotes the recruitment of eosinophils,dendritic cells (antigen presenting cells) and T cells, which in turn inincreases cell recruitment and activation. Clinically, montelukast hasbeen shown to increase FEV1 by 15% in minutes to hours followingadministration.

Both levocetirizine and montelukast affect eosinophilquantity/migration. An eosinophilic infiltrate is considered a hallmarkof inflammation.

In conclusion, given the multiple sites of action within theinflammatory pathway underscored by the safety of the molecules, thecombination of levocetirizine and montelukast will improve outcomes overexisting protocols, and decrease morbidity and mortality in this patientpopulation.

What is claimed is:
 1. A method of treating traumatic injury or asymptom of traumatic injury in a patient in need thereof comprisingadministering an effective amount of a combination of levocetirizine andmontelukast.
 2. The method of claim 1, wherein the combination isadministered at the onset of symptoms.
 3. The method of claim 1, whereinthe combination is administered at the time of diagnosis.
 4. The methodof claim 1, wherein the combination is administered in a sequentialmanner.
 5. The method of claim 1, wherein the combination isadministered in a substantially simultaneous manner.
 6. The method ofclaim 1, further comprising the administration of an additional activeagent.
 7. The method of claim 6, wherein the additional active agent isselected from the group consisting of an antibiotic, antiviral,anti-parasitic, antifungal, vasopressor, diuretic, anticoagulant,anti-seizure medication, proton pump inhibitor, H2 receptor antagonist,antipyretic agent, anti-inflammatory drug, anti-neoplastic drug, andcombinations thereof.
 8. The method of claim 6, wherein the additionalactive agent is an antibiotic selected from the group consisting ofvancomycin, meropenem, amoxicillin/beta clauvulanic acid, levofloxacin,piperacillin/tazobactam, ceftriaxone, clindamycin, azithromycin,trimethoprim/sulfamethoxazole, doxycycline or combinations thereof. 9.The method of claim 1, wherein the combination is administered to thepatient by one or more of the routes consisting of enteral, intravenous,intraperitoneal, inhalation, intramuscular, subcutaneous and oral. 10.The method of claim 1, wherein the levocetirizine and montelukast areadministered by the same route.